Understanding trends and variation in paediatric fracture management in England

Annual fracture incidence rates per 100,000 (2023/2024)

Forearm/wrist fractures are the most common followed by elbow fractures.

Tibia/Fibula fractures are most common in those aged 0-4 years

Elbow fractures are most common in those aged 5-10 years

In the 11-16 year old age group all fracture types are more common in males compared to females, with males aged 11-16 yrs old having the highest incidence of clavicle, forearm and toe fractures.

For all fracture types the incidence rates are high in the Cornwall and Isles of Scilly ICB area. There are also generally high rates of several fracture types in the Gloucester and Hereford and Worcestershire ICB areas.

The fracture incidence rate is generally lowest is the South East of England, particularly in the London area.

The majority of fractures are recorded within the emergency care dataset under just a few snomed codes.

There is a trend towards a reduction in the proportion of emergency department attendances for upper limb fractures where a follow-up appointment is given.

As a result of the COVID-19 pandemic the proportion of follow up appointments conducted face to face has fallen significantly.

The percentage of forearm fractures manipulated in the emergency department has increased over the last 6 yrs, with a large increase seen during the COVID-19 pandemic. There is also a noticeable seasonal trend with a greater percentage of fractures manipulated in the emergency department during the summer months.

The percentage of tibia/fibula fractures manipulated in the emergency department has also increased, but there is little change in the other fracture types over time.

The percentage of forearm fractures manipulated in theatre has decreased significantly over the last 6 yrs, with a greater percentage of fractures manipulated in theatre during the summer months.

The percentage of tibia/fibula fractures manipulated in theatre as also decreased.

The percentage of emergency department attendances for fractures that result in a referral/outpatient attendance for physiotherapy are low, and appears generally unchanged over the last 6 years.

The majority of fractures of all types are x-rayed in the emergency department, although the percentage of toe fractures x-rayed is slightly lower.

There is a trend towards a greater proportion of fractures being seen in urgent treatment/ walk-in centres rather than emergency departments.

It could be hypothesised that if the proportion of fractures seen in the emergency department continues to decrease that the opportunities to increase manipulations of fractures in the emergency department could become more limited over time.

These proportions are slightly lower than seen in the GIRFT study, the discrepancy is likely because they included all forearm and wrist fractures, whereas we have excluded open fractures, which are assumed to all require treatment in theatre. Also, GIRFT include re-manipulations in theatre whilst we have excluded these.

GIRFT uses the total A&E attendances as the denominator, but since we find that the incidence rates vary by area the proportion of A&E attendances due to fractures may be different in different areas, so to determine variability by trust using the number of each fracture type as the denominator may be more appropriate.

Children are more likely to be given a follow-up appointment if they are

• male

• 11-16 yrs old

• from an Asian or Black background

• from a more affluent area

They are also more likely to have a follow-up appointment if they attended

• an emergency department

• on a weekend

• at nighttime

Those attending in more recent years were less likely to have a follow-up appointment, further indicating their has been a move towards fewer follow-up appointments.

Includes only forearm fractures that are manipulated in either the emergency department or in theatre to determine what factors might be influencing the decision to manipulate a fracture in theatre rather than in the emergency department.

Children are more likely to have a fracture manipulated in theatre if they are

• female

• under the age of 5

• white

• from a more deprived area

They are also more likely to have a manipulation in theatre if they attended

• an urgent treatment centre

• on a weekend

• at nighttime

• in the summer

Those attending in more recent years were less likely to have their fracture manipulated in theatre, further indicating their has been a move towards manipulating more fractures in the emergency department.